Teton Valley CHNA 2016_Full

Teton Valley Health Care Driggs, Idaho

Community Health Needs Assessment and Implementation Strategy Adopted by Board Resolution September 28, 20161 1

Response to Schedule h (Form 990) Part V B 4 & Schedule h (Form 990) Part V B 9

Dear Community Member: At Teton Valley Health Care, Inc. (TVHC), we have spent more than 76 years providing high-quality compassionate healthcare to the greater Driggs community. The “2016 Community Health Needs Assessment� identifies local health and medical needs and provides a plan of how TVHC will respond to such needs. This document suggests areas where other local organizations and agencies might work with us to achieve desired improvements and illustrates one way we, TVHC, are meeting our obligations to efficiently deliver medical services.

In addition, in compliance with the Affordable Care Act, all not-for-profit hospitals are now required to develop a report on the medical and health needs of the communities they serve. We welcome you to review this document not just as part of our compliance with federal law, but of our continuing efforts to meet your health and medical needs.

TVHC will conduct this effort at least once every three years. The report produced three years ago is also available for your review and comment. As you review this plan, please see if, in your opinion, we have identified the primary needs of the community and if you think our intended response will lead to needed improvements.

We do not have adequate resources to solve all the problems identified. Some issues are beyond the mission of the hospital and action is best suited for a response by others. Some improvements will require personal actions by individuals rather than the response of an organization. We view this as a plan for how we, along with other area organizations and agencies, can collaborate to bring the best each has to offer to support change and to address the most pressing identified needs.

The report is a response to a federal requirement of not-for-profit hospitals to identify the community benefit they provide in responding to documented community need. Footnotes are provided to answer specific tax form questions; for most purposes, they may be ignored. Most importantly, this report is intended to guide our actions and the efforts of others to make needed health and medical improvements in our area.

I invite your response to this report. As you read, please think about how to help us improve health and medical services in our area. We all live in, work in, and enjoy this wonderful community together. Together, we can make our community healthier for every one of us.

Thank You, Keith Gnagey Chief Executive Officer Teton Valley Health Care

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TABLE OF CONTENTS Executive Summary ................................................................................................................................................................. 1 Approach ................................................................................................................................................................................. 3 Project Objectives ............................................................................................................................................................... 4 Overview of Community Health Needs Assessment .......................................................................................................... 4 Community Health Needs Assessment Subsequent to Initial Assessment ........................................................................ 5 Community Characteristics ................................................................................................................................................... 11 Definition of Area Served by the Hospital ........................................................................................................................ 12 Demographic of the Community ..................................................................................................................................... 13 Leading Causes of Death................................................................................................................................................... 16 Priority Populations .......................................................................................................................................................... 17 Social Vulnerability ........................................................................................................................................................... 18 Consideration of Written Comments from Prior CHNA ................................................................................................... 19 Conclusions from Public Input .......................................................................................................................................... 22 Summary of Observations: Comparison to Other Counties ............................................................................................. 23 Summary of Observations: Peer Comparisons ................................................................................................................. 24 Conclusions from Demographic Analysis Compared to National Averages ..................................................................... 26 Conclusions from Other Statistical Data ........................................................................................................................... 27 Existing Healthcare Facilities, Resources, & Implementation Strategy ................................................................................ 31 Significant Needs .............................................................................................................................................................. 33 Other Needs Identified During CHNA Process .................................................................................................................. 43 Overall Community Need Statement and Priority Ranking Score .................................................................................... 44 Appendix ............................................................................................................................................................................... 46 Appendix A – Written Commentary on Prior CHNA ......................................................................................................... 47 Appendix B – Identification & Prioritization of Community Needs .................................................................................. 53 Appendix C – National Healthcare Quality and Disparities Report .................................................................................. 60 Appendix D – Illustrative Schedule h (Form 990) Part V B Potential Response ............................................................... 70

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EXECUTIVE SUMMARY

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EXECUTIVE SUMMARY Teton Valley Health Care ("TVHC� or the "Hospital") has performed a Community Health Needs Assessment to determine the health needs of the local community, develop an implementation plan to outline and organize how to meet those needs, and fulfill federal requirements.

Data was gathered from multiple well-respected secondary sources to build an accurate picture of the current community and its health needs. A survey of a select group of Local Experts was performed to review the prior CHNA and provide feedback, and to ascertain whether the previously identified needs are still a priority. A second survey was distributed to the same group that reviewed the data gathered from the secondary sources and determined the Significant Health Needs for the community.

The Significant Health Needs for Teton County are: 1. Affordability/Accessibility 2. Mental Health/Suicide 3. Prevention/Wellness 4. Alcohol Abuse/Substance Abuse 5. Accidents The Hospital has developed implementation strategies for four of the five needs including activities to continue/pursue, community partners to work alongside, and leading and lagging indicators to track.

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APPROACH

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APPROACH Teton Valley Health Care ("TVHC” or the "Hospital") is organized as a not-for-profit hospital. A Community Health Needs Assessment (CHNA) is part of the required hospital documentation of “Community Benefit” under the Affordable Care Act (ACA), required of all not-for-profit hospitals as a condition of retaining tax-exempt status. A CHNA assures TVHC identifies and responds to the primary health needs of its residents.

This study is designed to comply with standards required of a not-for-profit hospital.2 Tax reporting citations in this report are superseded by the most recent 990 h filings made by the hospital.

In addition to completing a CHNA and funding necessary improvements, a not-for-profit hospital must document the following: 

Financial assistance policy and policies relating to emergency medical care



Billing and collections



Charges for medical care

Further explanation and specific regulations are available from Health and Human Services (HHS), the Internal Revenue Service (IRS), and the U.S. Department of the Treasury.3

Project Objectives TVHC partnered with Quorum Health Resources (Quorum) to:4 

Complete a CHNA report, compliant with Treasury – IRS



Provide the Hospital with information required to complete the IRS – 990h schedule



Produce the information necessary for the Hospital to issue an assessment of community health needs and document its intended response

Overview of Community Health Needs Assessment Typically, non-profit hospitals qualify for tax-exempt status as a Charitable Organization, described in Section 501(c)(3) of the Internal Revenue Code; however, the term 'Charitable Organization' is undefined. Prior to the passage of Medicare, charity was generally recognized as care provided to the less fortunate who did not have means to pay. With the introduction of Medicare, the government met the burden of providing compensation for such care.

In response, IRS Revenue ruling 69-545 eliminated the Charitable Organization standard and established the Community Benefit Standard as the basis for tax-exemption. Community Benefit determines if hospitals promote the health of a broad class of individuals in the community, based on factors including: 

An Emergency Room open to all, regardless of ability to pay

2

Federal Register Vol. 79 No. 250, Wednesday December 31, 2014. Part II Department of the Treasury Internal Revenue Service 26 CFR Parts 1, 53, and 602 3 As of the date of this report all tax questions and suggested answers relate to 2014 Draft Federal 990 schedule h instructions i990sh—dft(2) and tax form 4 Part 3 Treasury/IRS – 2011 – 52 Section 3.03 (2) third party disclosure notice & Schedule h (Form 990) V B 6 b

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

Surplus funds used to improve patient care, expand facilities, train, etc.



A board controlled by independent civic leaders



All available and qualified physicians granted hospital privileges

Specifically, the IRS requires: 

Effective on tax years beginning after March 23, 2012, each 501(c)(3) hospital facility is required to conduct a CHNA at least once every three taxable years and to adopt an implementation strategy to meet the community needs identified through such assessment.



The assessment may be based on current information collected by a public health agency or non-profit organization and may be conducted together with one or more other organizations, including related organizations.



The assessment process must take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge or expertise of public health issues.



The hospital must disclose in its annual information report to the IRS (Form 990 and related schedules) how it is addressing the needs identified in the assessment and, if all identified needs are not addressed, the reasons why (e.g., lack of financial or human resources).



Each hospital facility is required to make the assessment widely available and downloadable from the hospital website.



Failure to complete a CHNA in any applicable three-year period results in an excise tax to the organization of $50,000. For example, if a facility does not complete a CHNA in taxable years one, two, or three, it is subject to the penalty in year three. If it then fails to complete a CHNA in year four, it is subject to another penalty in year four (for failing to satisfy the requirement during the three-year period beginning with taxable year two and ending with taxable year four).



An organization that fails to disclose how it is meeting needs identified in the assessment is subject to existing incomplete return penalties.5

Community Health Needs Assessment Subsequent to Initial Assessment The Final Regulations establish a required step for a CHNA developed after the initial report. This requirement calls for considering written comments received on the prior CHNA and Implementation Strategy as a component of the development of the next CHNA and Implementation Strategy. The specific requirement is: “The 2013 proposed regulations provided that, in assessing the health needs of its community, a hospital facility must take into account input received from, at a minimum, the following three sources: (1) At least one state, local, tribal, or regional governmental public health department (or equivalent department or agency) with knowledge, information, or expertise relevant to

5

Section 6652

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the health needs of the community; (2) members of medically underserved, low-income, and minority populations in the community, or individuals or organizations serving or representing the interests of such populations; and (3) written comments received on the hospital facility’s most recently conducted CHNA and most recently adopted implementation strategy.6 …the final regulations retain the three categories of persons representing the broad interests of the community specified in the 2013 proposed regulations but clarify that a hospital facility must ‘‘solicit’’ input from these categories and take into account the input ‘‘received.’’ The Treasury Department and the IRS expect, however, that a hospital facility claiming that it solicited, but could not obtain, input from one of the required categories of persons will be able to document that it made reasonable efforts to obtain such input, and the final regulations require the CHNA report to describe any such efforts.”

Representatives of the various diverse constituencies outlined by regulation to be active participants in this process were actively solicited to obtain their written opinion. Opinions obtained formed the introductory step in this Assessment.

To complete a CHNA: “… the final regulations provide that a hospital facility must document its CHNA in a CHNA report that is adopted by an authorized body of the hospital facility and includes: (1) A definition of the community served by the hospital facility and a description of how the community was determined; (2) a description of the process and methods used to conduct the CHNA; (3) a description of how the hospital facility solicited and took into account input received from persons who represent the broad interests of the community it serves; (4) a prioritized description of the significant health needs of the community identified through the CHNA, along with a description of the process and criteria used in identifying certain health needs as significant and prioritizing those significant health needs; and (5) a description of resources potentially available to address the significant health needs identified through the CHNA. … final regulations provide that a CHNA report will be considered to describe the process and methods used to conduct the CHNA if the CHNA report describes the data and other information used in the assessment, as well as the methods of collecting and analyzing this data and information, and identifies any parties with whom the hospital facility collaborated, or with whom it contracted for assistance, in

6

Federal Register Vol. 79 No. 250, Wednesday December 31, 2014. Part II Department of the Treasury Internal Revenue Service 26 CFR Parts 1, 53, and 602 P. 78963 and 78964

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conducting the CHNA.”7 Additionally, a CHNA developed subsequent to the initial Assessment must consider written commentary received regarding the prior Assessment and Implementation Strategy efforts. We followed the Federal requirements in the solicitation of written comments by securing characteristics of individuals providing written comment but did not maintain identification data. “…the final regulations provide that a CHNA report does not need to name or otherwise identify any specific individual providing input on the CHNA, which would include input provided by individuals in the form of written comments.”8 Quorum takes a comprehensive approach to the solicitation of written comments. As previously cited, we obtained input from the required three minimum sources and expanded input to include other representative groups. We asked all participating in the written comment solicitation process to self-identify themselves into any of the following representative classifications, which is detailed in an Appendix to this report. Written comment participants selfidentified into the following classifications: (1) Public Health – Persons with special knowledge of or expertise in public health (2) Departments and Agencies – Federal, tribal, regional, State, or local health or other departments or agencies, with current data or other information relevant to the health needs of the community served by the hospital facility (3) Priority Populations – Leaders, representatives, or members of medically underserved, low income, and minority populations, and populations with chronic disease needs in the community served by the hospital facility. Also, in other federal regulations the term Priority Populations, which include rural residents and LGBT interests, is employed and for consistency is included in this definition (4) Chronic Disease Groups – Representative of or member of Chronic Disease Group or Organization, including mental and oral health (5) Broad Interest of the Community – Individuals, volunteers, civic leaders, medical personnel and others to fulfill the spirit of broad input required by the federal regulations Other (please specify) Quorum also takes a comprehensive approach to assess community health needs. We perform several independent data analyses based on secondary source data, augment this with Local Expert Advisor9 opinions, and resolve any data inconsistency or discrepancies by reviewing the combined opinions formed from local experts. We rely on secondary source data, and most secondary sources use the county as the smallest unit of analysis. We asked our local expert area residents to note if they perceived the problems or needs identified by secondary sources existed in their portion of the

7

Federal Register Op. cit. P 78966 As previously noted the Hospital collaborated and obtained assistance in conducting this CHNA from Quorum Health Resources (Quorum). & Response to Schedule h (Form 990) B 6 b 8 Federal Register Op. cit. P 78967 & Response to Schedule h (Form 990) B 3 h 9 “Local Expert” is an advisory group of at least 15 local residents, inclusive of at least one member self-identifying with each of the five Quorum written comment solicitation classifications, with whom the Hospital solicited to participate in the Quorum/Hospital CHNA process. Response to Schedule h (Form 990) V B 3 h

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county.10 Most data used in the analysis is available from public Internet sources and Quorum proprietary data from Truven. Any critical data needed to address specific regulations or developed by the Local Expert Advisor individuals cooperating with us in this study are displayed in the CHNA report appendix.

Data sources include:11 Website or Data Source

Data Element

Date Accessed

Data Date

www.countyhealthrankings.org

Assessment of health needs of Teton County compared to all state counties

October 10, 2015

2010 to 2012

www.communityhealth.hhs.gov

Assessment of health needs of Teton County compared to its national set of “peer counties”

October 10, 2015

2005 to 2011

Truven (formerly known as Thomson) Market Planner

Assess characteristics of the hospital’s primary service area, at a zip code level, based on classifying the population into various socio-economic groups, determining the health and medical tendencies of each group and creating an aggregate composition of the service area according to the proportion of each group in the entire area; and, to access population size, trends and socioeconomic characteristics.

March 22, 2016

2012 to 2016

www.capc.org and www.getpalliativecare.org

To identify the availability of palliative care programs and services in the area

October 10, 2015

2015

www.caringinfo.org and iweb.nhpco.org

To identify the availability of hospice programs in the country

October 10, 2015

2015

www.healthmetricsandevaluation.org To examine the prevalence of diabetic conditions and change in life expectancy

October 10, 2015

2000 to 2010

www.cdc.gov

October 10, 2015

2008 to 2010

To examine area trends for heart disease and stroke

10

Response to Schedule h (Form 990) Part V B 3 i The final regulations clarify that a hospital facility may rely on (and the CHNA report may describe) data collected or created by others in conducting its CHNA and, in such cases, may simply cite the data sources rather than describe the ‘‘methods of collecting’’ the data. Federal Register Op. cit. P 78967 & Response to Schedule h (Form 990) Part V B 3 d 11

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http://svi.cdc.gov

To identify the Social Vulnerability Index value

October 10, 2015

2010

www.CHNA.org

To identify potential needs from a variety of resource and health need metrics

October 10, 2015

2003 to 2015

www.datawarehouse.hrsa.gov

To identify applicable manpower shortage designations

October 10, 2015

2015

www.worldlifeexpectancy.com

To determine relative importance among 15 top causes of death

October 10, 2015

2013

Federal regulations surrounding CHNA require local input from representatives of particular demographic sectors. For this reason, Quorum developed a standard process of gathering community input. In addition to gathering data from the above sources: 

We deployed a CHNA “Round 1” survey to our Local Expert Advisors to gain input on local health needs and the needs of priority populations. Local Expert Advisors were local individuals selected according to criteria required by the Federal guidelines and regulations and the Hospital’s desire to represent the region’s geographically and ethnically diverse population. We received community input from 26 Local Expert Advisors. Survey responses started November 3, 2015 and ended with the last response on November 29, 2015.



Information analysis augmented by local opinions showed how Teton County relates to its peers in terms of primary and chronic needs and other issues of uninsured persons, low-income persons, and minority groups.

Respondents commented on whether they believe certain population groups (“Priority Populations”) need help to improve their condition, and if so, who needs to do what to improve the conditions of these groups.12



Local opinions of the needs of Priority Populations, while presented in its entirety in the Appendix, was abstracted in the following “take-away” bulleted comments ▪

Family planning for low income families is needed

▪

Most all of the priority populations struggle with transportation issues

▪

The Hispanic population and rural population are underserved

▪

Lack of support for mental health, domestic abuse, and the LGBT community

When the analysis was complete, we put the information and summary conclusions before our Local Expert Advisors13 who were asked to agree or disagree with the summary conclusions. They were free to augment potential conclusions with additional comments of need, and new needs did emerge from this exchange.14 Consultation with 21 Local Experts occurred again via an internet-based survey (explained below) beginning January 18, 2016 and ending February 29,

12

Response to Schedule h (Form 990) Part V B 3 f Response to Schedule h (Form 990) Part V B 3 h 14 Response to Schedule h (Form 990) Part V B 3 h 13

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2016.

Having taken steps to identify potential community needs, the Local Experts then participated in a structured communication technique called a "Wisdom of Crowds" method. The premise of this approach relies on a panel of experts with the assumption that the collective wisdom of participants is superior to the opinion of any one individual, regardless of their professional credentials.15 In the TVHC process, each Local Expert had the opportunity to introduce needs previously unidentified and to challenge conclusions developed from the data analysis. While there were a few opinions of the data conclusions not being completely accurate, the vast majority of comments agreed with our findings. We developed a summary of all needs identified by any of the analyzed data sets. The Local Experts then allocated 100 points among the potential significant need candidates, including the opportunity to again present additional needs that were not identified from the data. A rank order of priorities emerged, with some needs receiving none or virtually no support, and other needs receiving identical point allocations.

We dichotomized the rank order of prioritized needs into two groups: “Significant” and “Other Identified Needs.” Our criteria for identifying and prioritizing Significant Needs was based on a descending frequency rank order of the needs based on total points cast by the Local Experts, further ranked by a descending frequency count of the number of local experts casting any points for the need. By our definition, a Significant Need had to include all rank ordered needs until at least fifty percent (50%) of all points were included and to the extent possible, represented points allocated by a majority of voting local experts. The determination of the break point — “Significant” as opposed to “Other” — was a qualitative interpretation by Quorum and the TVHC executive team where a reasonable break point in rank order occurred.16

15 16

Response to Schedule h (Form 990) Part V B 5 Response to Schedule h (Form 990) Part V B 3 g

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COMMUNITY CHARACTERISTICS

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Definition of Area Served by the Hospital17

TVHC, in conjunction with Quorum, defines its service area as Teton County in Idaho, which includes the following ZIP codes:18 83422 – Driggs

83424 – Felt

83452 – Tetonia

83455 – Victor

83414 – Alta, Wyoming

In 2014, the Hospital received 81.7% of its patients from this area.19

17

Responds to IRS Schedule h (Form 990) Part V B 3 a The map above amalgamates zip code areas and does not necessarily display all county zip codes represented below 19 Truven MEDPAR patient origin data for the hospital; Responds to IRS Schedule h (Form 990) Part V B 3 a 18

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Demographic of the Community20 21 County

State

U.S.

2016 Population22

10,430

1,662,154

322,431,073

% Increase/Decline

3.7%

5.3%

3.7%

Estimated Population in 2021

10,816

1,750,200

334,341,965

% White, non-Hispanic

80.2%

82.2%

61.3%

% Hispanic

17.7%

12.3%

17.8%

Median Age

36.3

35.9

38.0

$54,896

$48,905

$55,072

Unemployment Rate

4.0%

3.9%

4.9%

% Population >65

9.1%

14.7%

15.1%

% Women of Childbearing Age

19.5%

19.3%

19.6%

Median Household Income

20

Responds to IRS Schedule h (Form 990) Part V B 3 b The tables below were created by Truven Market Planner, a national marketing company 22 All population information, unless otherwise cited, sourced from Truven (formally Thomson) Market Planner 21

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The population was also examined according to characteristics presented in the Claritas Prizm customer segmentation data. This system segments the population into 66 demographically and behaviorally distinct groups. Each group, based on annual survey data, is documented as exhibiting specific health behaviors.

The makeup of the service area, according to the mix of Prizm segments and its characteristics, is contrasted to the national population averages to determine probable lifestyle and medical conditions present in the population. The national average, or norm, is represented as 100%. Where Teton County varies more than 5% above or below that norm (that is, less than 95% or greater than 105%), it is considered significant.

Items in the table with red text are viewed as statistically important adverse potential findings—in other words, these are health areas that need improvement in the Teton County area. Items with blue text are viewed as statistically important potential beneficial findings—in other words, these are areas in which Teton County is doing better than other parts of the country. Items with black text are viewed as either not statistically different from the national norm or neither a favorable nor unfavorable finding—in other words more or less on par with national trends.

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Health Service Topic

Demand as % of National

% of Population Affected

Health Service Topic

Weight / Lifestyle

Demand as % of National

% of Population Affected

Cancer

BMI: Morbid/Obese Vigorous Exercise

99.6%

30.6%

Mammography in Past Yr

93.2%

42.5%

108.4%

62.2%

Cancer Screen: Colorectal 2 yr

89.7%

22.9%

Chronic Diabetes

88.7%

11.1%

Cancer Screen: Pap/Cerv Test 2 yr

95.2%

57.1%

Healthy Eating Habits

87.3%

25.9%

Routine Screen: Prostate 2 yr

94.2%

30.2%

Ate Breakfast Yesterday

99.3%

78.9%

Slept Less Than 6 Hours

125.1%

17.1%

Chronic Lower Back Pain

84.2%

19.9%

Consumed Alcohol in the Past 30 Days

84.1%

45.3%

Chronic Osteoporosis

83.6%

8.3%

Consumed 3+ Drinks Per Session

105.6%

29.9%

Behavior

Orthopedic

Routine Services FP/GP: 1+ Visit

104.6%

92.3%

I Will Travel to Obtain Medical Care

93.8%

21.4%

Used Midlevel in last 6 Months

109.3%

45.2%

I am Responsible for My Health I Follow Treatment Recommendations

100.4%

65.6%

OB/Gyn 1+ Visit

91.8%

42.3%

97.4%

50.5%

Medication: Received Prescription

97.4%

58.8%

Pulmonary

Internet Usage

Chronic COPD

80.1%

3.2%

Use Internet to Talk to MD

79.3%

9.6%

Tobacco Use: Cigarettes

100.2%

25.4%

Facebook Opinions

76.9%

7.9%

Looked for Provider Rating

94.7%

13.4%

Heart Chronic High Cholesterol

93.5%

20.5%

Routine Cholesterol Screening

93.1%

47.3%

Emergency Room Use

97.2%

32.9%

Chronic Heart Failure

134.7%

5.3%

Urgent Care Use

111.0%

25.8%

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Leading Causes of Death Cause of Death

Rank among all counties in ID

Rate of Death per 100,000 age adjusted

(#1 rank = worst in state)

ID

Teton

Observation (Compared to U.S. average)

ID Rank

Teton Rank

1

2

Heart Disease

39 of 43

145.4

153.0

Lower than expected

2

1

Cancer

42 of 43

156.2

120.2

Lower than expected

3

4

Accidents

11 of 43

47.7

68.2

Higher than expected

4

5

Stroke

36 of 43

35.4

41.8

Lower than expected

5

3

Lung

40 of 43

46.7

26.9

Lower than expected

6

8

Suicide

7 of 43

19.2

23.4

Higher than expected

7

7

Alzheimer's

24 of 43

21.0

18.9

As expected

8

9

Flu - Pneumonia

38 of 43

15.1

11.1

Lower than expected

9

6

Diabetes

40 of 43

23.8

11.0

Lower than expected

10

12

Parkinson's

22 of 43

8.8

7.1

Higher than expected

11

11

Kidney

39 of 43

8.8

6.4

Lower than expected

12

14

Blood Poisoning

26 of 43

5.7

4.5

Lower than expected

13

10

Liver

43 of 43

11.7

2.4

Lower than expected

14

13

Hypertension

43 of 43

8.0

0.8

Lower than expected

15

15

Homicide

N/A

2.0

N/A

Lower than expected

Condition

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Priority Populations23 Information about Priority Populations in the service area of the Hospital is difficult to encounter if it exists. Our approach is to understand the general trends of issues impacting Priority Populations and to interact with our Local Experts to discern if local conditions exhibit any similar or contrary trends. The following discussion examines findings about Priority Populations from a national perspective.

We begin by analyzing the National Healthcare Quality and Disparities Reports (QDR), which are annual reports to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129). These reports provide a comprehensive overview of the quality of healthcare received by the general U.S. population and disparities in care experienced by different racial, ethnic, and socioeconomic groups. The purpose of the reports is to assess the performance of our health system and to identify areas of strengths and weaknesses in the healthcare system along three main axes: access to healthcare, quality of healthcare, and priorities of the National Quality Strategy (NQS). The complete report is provided in Appendix C.

We asked a specific question to our Local Expert Advisors about unique needs of Priority Populations. We reviewed their responses to identify if any of the above trends were obvious in the service area. Accordingly, we place great reliance on the commentary received from our Local Expert Advisors to identify unique population needs to which we should respond. Specific opinions from the Local Expert Advisors are summarized below:24

23 24



Family planning for low income families is needed



Most all of the priority populations struggle with transportation issues



The Hispanic population and rural population are underserved



Lack of support for mental health, domestic abuse, and the LGBT community

http://www.ahrq.gov/research/findings/nhqrdr/nhqdr14/index.html Responds to IRS Schedule h (Form 990) Part V B 3 i All comments and the analytical framework behind developing this summary appear in Appendix A

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Social Vulnerability Social vulnerability refers to the resilience of communities when confronted by external stresses on human health, stresses such as natural or human-caused disasters, or disease outbreaks.

Teton County zip codes fall into the second lowest quartile of social vulnerability.

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Consideration of Written Comments from Prior CHNA A group of 26 individuals provided written comment in regard to the 2013 CHNA. Our summary of this commentary produced the following points, which were introduced in subsequent considerations of this CHNA. Commenter characteristics: Local Experts Offering Solicited Written Comments on 2013 Yes (Applies Priorities and Implementation Strategy to Me) 1) Public Health Expertise 1 2) Departments and Agencies with relevant data/information regarding health needs of the community served by the hospital 2 3) Priority Populations 5 4) Representative/Member of Chronic Disease Group or Organization 1 5) Represents the Broad Interest of the Community 15 Other Answered Question Skipped Question

No (Does Not Apply to Me) 22

Response Count 23

20 18

22 23

22 9

23 24 24 2

Priorities from the last assessment where the Hospital intended to seek improvement were: 

Affordability – issue was provide broader access to affordable healthcare



Mental Health/Suicide – issue was to improve awareness and access to mental health services



Alcohol Abuse/Substance Abuse – issue was to decrease substance abuse incidence



Palliative Care and Hospice – issue was to increase awareness and education about existing palliative and hospice care



Accidents – issue was to decrease the number of deaths caused by accidents



Prevention/Wellness – issue was to increase public awareness of prevention/wellness resources



Compliance Behavior – issue was to increase compliance with treatment efforts

TVHC received the following verbatim responses to the question: “Comments or observations about this set of needs as being the most appropriate for the Hospital to take on in seeking improvements?”

Should the Hospital continue to consider each need identified as most important in the 2013 CHNA report as the most important set of health needs currently confronting residents in the county?

Yes Affordability Mental Health/Suicide Alcohol Abuse/Substance Abuse Palliative Care and Hospice Accidents

No 19 16 19 14 15

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7 7 6 8 8 Page 19 Proprietary and Confidential

Prevention/Wellness Compliance Behavior











18 13

1 5

7 8

Specific comments or observations about Affordability as being among the most significant needs for the Hospital to work on to seek improvements?

▪

Health care is expensive in general. Not sure how many people take part in the annual blood draw or utilize discounted services.

▪

I agree that this is a top priority, especially in a rural community that is a 90+ minute drive away from a populated area offering more competitively priced healthcare options. Such travel is not realistic for most of us.

▪

Affordability of insurance is a continuing problem. Even more significant is the coverage available. The insurance plans provide catastrophic coverage rather than full coverage.

Specific comments or observations about Mental Health/Suicide as being among the most significant needs for the Hospital to work on to seek improvements?

▪

Very involved in the mental health of the community...nothing more required.

▪

Absolutely agree with this. Our suicide rates are shamefully high and the obstacles to adequate, highquality mental healthcare in our community are huge.

▪

Poor mental health contributes to many of these other issues.

▪

Mental health coverage is limited by insurers, creating an additional barrier.

Specific comments or observations about Alcohol Abuse/Substance Abuse as being among the most significant needs for the Hospital to work on to seek improvements?

▪

Agreed. Currently, there are absolutely zero local options for high-quality substance abuse treatment.

Residents must travel to Jackson, WY or to the Rexburg/Idaho Falls area. This is an unrealistic obstacle to service for many.

▪

Substance and alcohol abuse is a significant challenge facing almost every community. Early education is helpful in preventing abuse.

Specific comments or observations about Palliative Care and Hospice as being among the most significant needs for the Hospital to work on to seek improvements?

▪

I am completely ignorant on this issue and cannot offer any helpful insights. However, I do believe this need is currently being met by Avalon.

▪

See previous comments on this topic.

Specific comments or observations about Accidents as being among the most significant needs for the Hospital to work on to seek improvements?

▪

I am unclear on this topic, also. I had no idea our accident rates were so high.

▪

There are a lot of unsafe behaviors in the community. It is common to see children and adults not using

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their seatbelts. 



Specific comments or observations about Prevention/Wellness as being among the most significant needs for the Hospital to work on to seek improvements?

▪

I need a better description of Prevention/Wellness to offer any helpful insights.

▪

Wellness and prevention efforts are of paramount importance.

Specific comments or observations about Compliance Behavior as being among the most significant needs for the Hospital to work on to seek improvements?

▪

I'd love to hear what medical professionals have to say about this topic, as I am uninformed and am surely guilty of this myself.

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Conclusions from Public Input Our group of 26 Local Expert Advisors participated in an online survey to offer opinions about their perceptions of community health needs and the potential needs of unique populations. Complete verbatim written comments appear in the Appendix to this report.

TVHC received the following responses to the question: “Should the Hospital continue to consider each need identified as most important in the 2013 CHNA report as the most important set of health needs currently confronting residents in the county? Please add any additional information you would like us to understand.” 

These all makes sense as focus areas. I would add food/nutrition and family planning.



Significant improvement with access to mental health care.



I do believe there is now hospice care available in Teton Valley through Avalon Home Health Care and Hospice.

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Summary of Observations: Comparison to Other Counties Health Outcomes In a health status classification termed “Health Outcomes”, Teton ranks number 9 among the 42 ranked Idaho counties (best being #1). Premature Death (deaths prior to age 75) presents better values (longer survivability) than on average for the US and Idaho.

Health Factors In another health status classification “Health Factors”, Teton County ranks number 10 among the 42 ranked Idaho counties. The following indicators compared to ID average and to national top 10% performance present such poor values it warrants investigating how to improve: 

Access to Exercise Opportunities – Teton 58% which is considerably below ID avg. 79% and US best of 92%



Excessive Drinking – Teton 20% of residents compared to ID 15% and US best of 10%

Clinical Care In the “Clinical Care” classification, Teton County ranks number 30 among the 42 ranked Idaho counties. The following indicators compared to ID average and to national top 10% performance present such poor values it warrants investigating how to improve: 

Uninsured – Teton 26% of residents compared to ID 18% and US best of 11%



Population to Primary Care Physician – Teton 1,675:1 which is worse than the ID avg. 1,618:1 and US best of 1,045:1



Population to Dentist – Teton 1,713:1 which is worse than the ID avg. 1,565:1 and US best of 1,377:1



Population to Mental Health Provider – Teton 934:1 which is more than the ID avg. of 554:1 and US best of 386:1

Social and Economic Factors In the “Social and Economic Factors” classification, Teton County ranks number 11 among the 42 ranked Idaho counties.

The following indicators compared to ID average and to national top 10% performance present such poor values it warrants investigating how to improve: 

Children in Poverty – Teton 20% which is above the ID avg. 19% and US best of 13%



Number of Social Associations – Teton 3.0 per 10,000 residents less than half the ID avg. of 7.7 and about 13% of the US best of 22



Injury Deaths – Teton 82 deaths per 100,000 residents compared to ID 66 and US best of 50

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Summary of Observations: Peer Comparisons The Federal Government administers a process to allocate all counties into "Peer" groups. County "Peer" groups have similar social, economic, and demographic characteristics. Health and wellness observations when Teton County is compared to its national set of Peer Counties and compared to national rates result in the following: Mortality 

Better 



Cancer; Male Life Expectancy

Worse 

Unintentional Injury (including motor vehicle) – 65.3 deaths per 100,000; 3rd worst among 13 peer counties; US avg. 50.8

Morbidity 

Better 



Adult Obesity; Alzheimer’s Diseases/Dementia; Cancer; Gonorrhea; Older Adult Depression; Preterm Births; Syphilis

Worse 

Nothing

Healthcare Access and Quality 

Better 



Nothing

Worse 

Cost Barrier to Care – 21.8% of adults not visiting doctor due to cost; worst among 13 peer counties; US avg. 15.6%



Uninsured – 28.6% of population without health insurance; 2nd worst among 13 peer counties; US avg.

17.7%

Health Behaviors 

Better 



Adult Smoking

Worse 

Adult Female Routine Pap Tests – 63.9% of adult women; worst among 13 peer counties; US avg. 77.3%

Social Factors 

Better 

Children in Single-Parent Households; Violent Crime

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

Worse 

High Housing Costs – 35.8% of residents; 2nd worst among 13 peer counties; US avg. 27.3%



No High School Diploma – 11.9% of adults; 3rd worst among 13 peer counties; US avg. 14.4%



Poverty – 13.4% of individuals; worst among 13 peer counties; US avg. 16.3%

Physical Environment 

Better 



Air Quality; Limited Access to Healthy Food; Living Near Highways

Worse 

Housing Stress – 39.6% of housing defined as stress; worst among 13 peer counties; US avg. 28.1%

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Conclusions from Demographic Analysis Compared to National Averages The 2016 population for Teton County is estimated to be 10,430 and expected to increase at a rate of 3.7% through 2021. This is equal to the 3.7% national rate of growth, while Idaho’s population is expected to increase by 4.4%. In 2021, Teton County anticipates a population of 10,816.

Population estimates indicate the 2016 median age for the county is 36.3 years, slightly older than the Idaho median age (35.9) but younger than the national median age of 38.0 years. The 2016 Median Household Income for the area is $54,896, higher than the Idaho median income of $48,905 but lower than the national median income of $55,072.

Median Household Wealth value is higher than both the Idaho and national average. Median Home Value for Teton ($225,943) is also higher than both the Idaho median of $174,928 and the national median of $192,364. Teton's unemployment rate as of January 2016 was 4.0%, which is higher than the 3.9% statewide but lower than the 4.9% national civilian unemployment rate.

The portion of the population in the county over 65 is 9.1%, compared to Idaho (14.7%) and the national average (15.1%). The portion of the population of women of childbearing age is 19.5%, slightly higher than the Idaho average of 19.3% but lower than the national rate of 19.6%. 80.2% of the population is White non-Hispanic. The largest minority is the Hispanic population which comprises 17.7% of the total.

The following areas were identified from a comparison of the county to national averages. Metrics impacting more than 30% of the population and statistically significantly different from the national average include the following. All are considered adverse: 

Routine Cholesterol Screening is 6.9% below average impacting 47.3% of the population



Mammography in the Past Year is 6.8% below average impacting 42.5% of the population



Routine Prostate Screening is 5.8% below average impacting 30.2 of the population



OB/GYN Visit is 8.2% below average impacting 42.3% of the population

Metrics impacting more than 30% of the population and statistically significantly different from the national average include the following. All are considered beneficial: 

Vigorous Exercise is 8.4% above average impacting 62.2% of the population



Consumed Alcohol in the Past 30 Days is 15.9% below average impacting 45.3% of the population



Used Midlevel in Last 6 Months is 9.3% above average impacting 45.2% of the population

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Conclusions from Other Statistical Data Among the Top 15 Causes of Death in the U.S., only Alzheimer’s occurred at an expected rate in Teton County.

Accidents, Suicide, and Parkinson’s occurred at higher rates than expected. Heart Disease, Cancer, Stroke, Lung Disease, Flu/Pneumonia, Diabetes, Kidney Disease, Blood Poisoning, Liver Disease, Hypertension, and Homicide occurred at lower rates than expected. The Top 10 Causes of Death in Teton County are: 1.

Heart Disease with Teton ranking #39 among 43 ID Counties (where #1 is worst in state)

2.

Cancer ranking #42 in ID

3.

Accidents ranking #11 in ID

4.

Stroke ranking #36 in ID

5.

Lung Disease ranking #40 in ID

6.

Suicide ranking #7 in ID

7.

Alzheimer's ranking #24 in ID

8.

Flu/Pneumonia ranking #38 in ID

9.

Diabetes ranking #40 in ID

10. Parkinson’s ranking #22 in ID

The Institute for Health Metrics and Evaluation at the University of Washington analyzed all 3,143 US counties or equivalents applying small area estimation techniques to the most recent county information.

Unfavorable Teton Valley County measures that are worse than the US avg. and had an unfavorable change: 

Female Heavy Drinking - As of 2012, 7.9% of females are heavy drinkers; value increased 3.3 percentage points since 2005

Unfavorable Teton Valley County measures that are worse than the US avg. but had a favorable change: 

None

Desirable Teton Valley County measures better than or the same as the US avg. but had an unfavorable change: 

Male Heavy Drinking – As of 2012, 9.8% of males are heavy drinkers; value increased 2.6 pct points since 2005



Male Binge Drinking – As of 2012, 22.1% of males are binge drinkers; value increased 2.1 pct points since 2002



Female Binge Drinking – As of 2012, 10.0% of females are binge drinkers; value increased 0.3 pct points since 2002



Male Obesity – As of 2011, 31.2% of males are obese; value increased 8.0 pct points since 2001



Female Obesity – As of 2011, 29.2% of females are obese; value increased 6.8 pct points since 2001

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

Male Physical Activity – As of 2011, recommended physical activity for males is at 61.3%; value decreased 6.8 pct points since 2001

Desirable Teton Valley County measures better than or the same as the US avg. and had a favorable change: 

Male Life Expectancy – As of 2013, male life expectancy is at 77.8 years; value increased 4.4 years since 1985



Female Life Expectancy – As of 2013, female life expectancy is at 81.5 years; value increased 2.0 years since 1985



Male Smoking – As of 2012, male smoking is at 16.4%; value decreased 4.3 pct points since 1996



Female Smoking – As of 2012, female smoking is at 12.1%; value decreased 1.5 pct points since 2012



Female Physical Activity – As of 2011, recommended physical activity for females is at 60.8%; value increased 2.5 pct points since 2001

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Conclusions from Prior CHNA Implementation Activities Worksheet 4 of Form 990 h can be used to report the net cost of community health improvement services and community benefit operations.

“Community health improvement services” means activities or programs, subsidized by the health care organization, carried out or supported for the express purpose of improving community health. Such services do not generate inpatient or outpatient revenue, although there may be a nominal patient fee or sliding scale fee for these services.

“Community benefit operations” means: 

activities associated with community health needs assessments, administration, and



the organization's activities associated with fundraising or grant-writing for community benefit programs.

Activities or programs cannot be reported if they are provided primarily for marketing purposes or if they are more beneficial to the organization than to the community. For example, the activity or program may not be reported if it is designed primarily to increase referrals of patients with third-party coverage, required for licensure or accreditation, or restricted to individuals affiliated with the organization (employees and physicians of the organization).

To be reported, community need for the activity or program must be established. Community need can be demonstrated through the following: 

A CHNA conducted or accessed by the organization.



Documentation that demonstrated community need or a request from a public health agency or community group was the basis for initiating or continuing the activity or program.



The involvement of unrelated, collaborative tax-exempt or government organizations as partners in the activity or program carried out for the express purpose of improving community health.

Community benefit activities or programs also seek to achieve a community benefit objective, including improving access to health services, enhancing public health, advancing increased general knowledge, and relief of a government burden to improve health. This includes activities or programs that do the following: 

Are available broadly to the public and serve low-income consumers.



Reduce geographic, financial, or cultural barriers to accessing health services, and if they ceased would result in access problems (for example, longer wait times or increased travel distances).



Address federal, state, or local public health priorities such as eliminating disparities in access to healthcare services or disparities in health status among different populations.



Leverage or enhance public health department activities such as childhood immunization efforts.



Otherwise would become the responsibility of government or another tax-exempt organization.



Advance increased general knowledge through education or research that benefits the public.

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Activities reported by the Hospital in its implementation efforts and/or its prior year tax reporting included: 

Financial Assistance - $254,613



Community Health Improvement Services & Community Benefit Operations - $62,194



Subsidized Health Services - $4,278



Contributions from Community Benefit - $13,573



TOTAL = $334,658

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EXISTING HEALTHCARE FACILITIES, RESOURCES, & IMPLEMENTATION STRATEGY

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SIGNIFICANT HEALTH NEEDS We used the priority ranking of area health needs by the Local Expert Advisors to organize the search for locally available resources as well as the response to the needs by TVHC.25 The following list: 

Identifies the rank order of each identified Significant Need



Presents the factors considered in developing the ranking



Establishes a Problem Statement to specify the problem indicated by use of the Significant Need term



Identifies TVHC current efforts responding to the need including any written comments received regarding prior TVHC implementation actions



Establishes the Implementation Strategy programs and resources TVHC will devote to attempt to achieve improvements



Documents the Leading Indicators TVHC will use to measure progress



Presents the Lagging Indicators TVHC believes the Leading Indicators will influence in a positive fashion, and



Presents the locally available resources noted during the development of this report as believed to be currently available to respond to this need.

In general, TVHC is the major hospital in the service area. Teton Valley Health Care (TVHC) is a 13-licensed bed, critical access hospital located in Driggs, Idaho. The next closest facilities are outside the service area and include: 

St. John’s Medical Center in Jackson, WY, 34 miles (50 minutes)



Madison Memorial Hospital in Rexburg, ID, 46 miles (56 minutes)



Eastern Idaho Regional Medical Center in Idaho Falls, ID, 74 miles (82 minutes)

All data items analyzed to determine significant needs are “Lagging Indicators,” measures presenting results after a period of time, characterizing historical performance. Lagging Indicators tell you nothing about how the outcomes were achieved. In contrast, the TVHC Implementation Strategy uses “Leading Indicators.” Leading Indicators anticipate change in the Lagging Indicator. Leading Indicators focus on short-term performance, and if accurately selected, anticipate the broader achievement of desired change in the Lagging Indicator. In the Quorum application, Leading Indicators also must be within the ability of the hospital to influence and measure.

25

Response to IRS Schedule h (Form 990) Part V B 3 e

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Significant Needs 1. AFFORDABILITY/ACCESSIBILITY – 2013 Significant Need; Local Expert concern; 21.8% of adults not visiting doctor due to cost; 28.6% worst among peer counties for affordability; worst among peers for affordability; 2nd worst among peers for accessibility Public comments received on previously adopted implementation strategy: 

1. Since our rates of health insurance were so low in 2013, perhaps a program aimed at providing assistance in applying for benefits could be helpful. Not sure how much as changed with the Affordable Health Care Act, though, so this may no longer be a necessity? 2. An increase in funds raised by the hospital to help cover indigent care and/or provide financial assistance to working families would also be useful. Perhaps this would be a good fit for the Hospital Foundation? It's a very compelling cause and could be marketed to the public and potential donors as a way to keep overall costs down for everyone.



This must be legislated.

TVHC services, programs, and resources available to respond to this need include:26 

Financial Assistance Policies – sliding fee schedule for clinics, charity care policy for hospital and clinic (no cap)



Free Mammography Program – free, basic mammography screening for anyone who claims they cannot afford it; also includes radiologist reading and free follow-up visits



Annual health fair with reduced-cost lab screenings and free preventive screenings



Bilingual Community Outreach Coordinator – guides people through ACA, certified medical translator



Telemedicine – offerings for stroke, burns, and acute care (in affiliation with University of Utah Healthcare)



Community Resource Center of Teton Valley – underwrote operations costs



Extended hours on clinics



ACA counseling services



Free concussion screenings for local athletic teams (ages 8+)

Additionally, TVHC plans to take the following steps to address this need: 

Patient Portal – access to results, records, physician refills, make appointments; reduces transportation needs



Chronic Care Management – proactive communication with doctors/specialists facilitated by dedicated nurse coordinator

TVHC evaluation of impact of actions taken since the immediately preceding CHNA:

26



Established 50 pediatrics in medical home program



111 concussion screenings performed



Provided free mammography screenings

This section in each need for which the hospital plans an implementation strategy responds to Schedule h (Form 990) Part V Section B 3 c

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

Added cardiology, dermatology, pulmonology specialties, increased neurology and pain management services

Anticipated results from TVHC Implementation Strategy Yes, Implementation Strategy Addresses

Community Benefit Attribute Element 1. Available to public and serves low income consumers

X

2. Reduces barriers to access services (or, if ceased, would result in access problems)

X

3. Addresses disparities in health status among different populations

X

4. Enhances public health activities

X

Implementation Strategy Does Not Address

5. Improves ability to withstand public health emergency

X

6. Otherwise would become responsibility of government or another tax-exempt organization

X

7. Increases knowledge; then benefits the public

X

The strategy to evaluate TVHC intended actions is to monitor change in the following Leading Indicator: 

Increase in the number of clinic visits = 17,711 as of September 30, 2015 (FYE 2015)

The change in the Leading Indicator anticipates appropriate change in the following Lagging Indicator: 

Reduction in uninsured population in Teton County = 21.57% (chna.org)

TVHC anticipates collaborating with the following other facilities and organizations to address this Significant Need: Organization

Contact Name

Contact Information

Community Resource Center of Teton Valley

Megan O’Brien

info@crctv.org

Eastern Idaho Public Health Department

Cammie Durbin

208-354-2220

Teton County Board of County Commissioners (Indigent care)

Bill Leake

208-354-8775

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Other local resources identified during the CHNA process that are believed available to respond to this need: 27 Organization Four Peaks Urgent Care

Contact Name Dr. Scott Thomas

Contact Information 208-354-4757

27

This section in each need for which the hospital plans an implementation strategy responds to Schedule h (form 990) Part V Section B 3 c and Schedule h (Form 990) Part V Section B 11

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2. MENTAL HEALTH/SUICIDE – 2013 Significant Need; suicide #6 leading cause of death; 19.2 deaths per 100,000 – higher rate than expected Public comments received on previously adopted implementation strategy: 

Currently very involved and supportive of the mental health community and their projects.



Collaboration with the newly formed Community Resource Center. Collaboration with [Suicide Prevention Action Network] and Teton Valley Mental Health Coalition to further resources for free and subsidized counseling. These two organizations new, small, all-volunteer organizations that are limited by their capacity and could use assistance in procuring resources.



Support crisis counseling. Continue telepsychiatry.

TVHC services, programs, and resources available to respond to this need include: 

Telepsychiatry (ages 18+)



Community Resource Center – Executive Director is bilingual with a social work background and family counseling emphasis



Certified mental health counselor sees patients weekly (adolescent to geriatric)



Sponsored annual SPAN walk and active on local Board

Additionally, TVHC plans to take the following steps to address this need: 

Adolescent psychiatry offered in cooperation with the University of Utah



Tele-mental health in partnership with local behavioral health center in Idaho Falls; will assist in assessing and admitting patients as needed



Assessing expansion of telepsychiatry services and partnerships

TVHC evaluation of impact of actions taken since the immediately preceding CHNA: 

Increasing awareness and access to mental health services

Anticipated results from TVHC Implementation Strategy Community Benefit Attribute Element 1. Available to public and serves low income consumers 2. Reduces barriers to access services (or, if ceased, would result in access problems) 3. Addresses disparities in health status among different populations 4. Enhances public health activities 5. Improves ability to withstand public health emergency

Teton Valley Health Care, Driggs, Idaho Community Health Needs Assessment & Implementation Strategy

Yes, Implementation Strategy Addresses

Implementation Strategy Does Not Address

X X X X X

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Community Benefit Attribute Element

Yes, Implementation Strategy Addresses

6. Otherwise would become responsibility of government or another tax-exempt organization

X

7. Increases knowledge; then benefits the public

X

Implementation Strategy Does Not Address

The strategy to evaluate TVHC intended actions is to monitor change in the following Leading Indicator: 

Increasing number of people who use adult telepsychiatry = Begin tracking in 2016

The change in the Leading Indicator anticipates appropriate change in the following Lagging Indicator: 

2015 suicide death rate = 23.4 per 100,000

TVHC anticipates collaborating with the following other facilities and organizations to address this Significant Need: Organization

Contact Name

Contact Information

SPAN

Myra Kerr

myrakerr@gmail.com

Community Resource Center

Megan O’Brien

www.crctv.org

Teton Valley Mental Health Coalition

Adam Williamson

208-705-7898

Portneuf Medical Center

Dennis Carlson

dennisc@portmed.org 208-239-2033

Idaho Falls Behavioral Health Center University of Utah

208-529-6111 Nate Gladwell

nate.gladwell@hsc.utah.edu 801-581-3595

Other local resources identified during the CHNA process that are believed available to respond to this need: Organization

Contact Name

Jackson Hole Community Counseling Center Family Safety Network

Contact Information www.jhccc.org

Marc d’Amore

Teton Valley Health Care, Driggs, Idaho Community Health Needs Assessment & Implementation Strategy

208-354-8838

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3. PREVENTION/WELLNESS – 2013 Significant Need – Local Experts support Public comments received on previously adopted implementation strategy: 

Community education program in the schools, through the churches, partner with the local governments?



A patient's physician must champion the need for prevention and wellness.

TVHC services, programs, and resources available to respond to this need include: 

Free sugar screenings, discounted lab draws and screenings, carotid checks at health fairs around the area



Free concussion baseline testing



Free mammography screenings



Bundled, discounted pricing for colonoscopy screenings



Low-cost flu vaccines and sports physicals



State-funded vaccine program for pediatrics (vaccines provided by state, serviced by TVHC)



‘Doc Talk’ column in the newspaper providing healthcare information to the area



Coumadin Clinic



Senior Center health outreach (foot checks, sugar checking, blood pressure checks)



Dietician services

Additionally, TVHC plans to take the following steps to address this need: 

Looking to become a Patient-centered Medical Home (PCMH)



Added dermatology to screen for skin cancer



Investigate grants for adult vaccinations



Bringing in speakers to talk on a variety of health issues



Chronic Care Management – program specifically to address preventive care and get people caught up on preventive healthcare

TVHC evaluation of impact of actions taken since the immediately preceding CHNA: 

Increased awareness of preventive and wellness services

Anticipated results from TVHC Implementation Strategy Community Benefit Attribute Element

Yes, Implementation Strategy Addresses

1. Available to public and serves low income consumers

X

2. Reduces barriers to access services (or, if ceased, would result in access problems)

X

Teton Valley Health Care, Driggs, Idaho Community Health Needs Assessment & Implementation Strategy

Implementation Strategy Does Not Address

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Yes, Implementation Strategy Addresses

Community Benefit Attribute Element 3. Addresses disparities in health status among different populations

X

4. Enhances public health activities

X

5. Improves ability to withstand public health emergency

X

6. Otherwise would become responsibility of government or another tax-exempt organization

X

7. Increases knowledge; then benefits the public

X

Implementation Strategy Does Not Address

The strategy to evaluate TVHC intended actions is to monitor change in the following Leading Indicator: 

Number of patients enrolled in Chronic Care Program (launching in 2016)

The change in the Leading Indicator anticipates appropriate change in the following Lagging Indicator: 

Percentage of adults with BMI > 30.0 (Obese) = 26.3% (chna.org)

TVHC anticipates collaborating with the following other facilities and organizations to address this Significant Need: Organization

Contact Name

Contact Information

Eastern Idaho Public Health

Cammie

(208) 522-0310

Teton County School District

Monte Woolstenhulme

mrw@tsd401.org 208-354-2207

Teton Valley Hospital Foundation

Ann Loyola

208-354-6317 x.181

Other local resources identified during the CHNA process that are believed available to respond to this need: Organization

Contact Name

Various local fitness and recreation center

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Contact Information www.crctv.org (lists available on Community Resource Center website)

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4. ALCOHOL ABUSE/SUBSTANCE ABUSE – 2013 Significant Need; Local Experts support; excessive drinking above ID and US values Public comments received on previously adopted implementation strategy: 

I dream of the day when we can support a nonprofit substance abuse treatment center in Teton Valley. Any efforts by TVHC to bring this much needed resource into fruition would be incredibly appreciated. There are many, many challenges to working on a project of this scope, but the rewards would multiply exponentially and would include reductions in violence, poverty, accidents, crime, suicide, etc.



Consider supporting AA and NA chapters.

TVHC does not intend to develop an implementation strategy for this Significant Need 

We are unable to provide a substance abuse treatment center at this time. We do assist with prevention efforts through ad campaigns, financial and staffing support for collaborative partners such as the Community Resource Center of Teton Valley, and keeping updated referral information for people seeking help with substance abuse addictions. We also implement narcotics contracts between patients and their providers, and participate in the Idaho Prescription Monitoring program that shares prescription opioid information among pharmacies, healthcare professionals, and other care providers.

Federal classification of reasons why a hospital may cite for not developing an Implementation Strategy for a defined Significant Need 1. Resource Constraints

X

2. Relative lack of expertise or competency to effectively address the need

X

3. A relatively low priority assigned to the need 4. A lack of identified effective interventions to address the need 5. Need is addressed by other facilities or organizations in the community 6. Other Other local resources identified during the CHNA process that are believed available to respond to this need: Organization

Contact Name

LDS Family Services Addictions

Contact Information 208-529-5276 www.addictionrecovery.lds.org

Teton Valley Mental Health Coalition (lists of AA meetings)

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www.simeetings.com

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5. ACCIDENTS – 2013 Significant Need; #3 leading cause of death; 47.7 deaths per 100,000 – higher rate than expected; injury deaths higher than US and ID average Public comments received on previously adopted implementation strategy: 

Community education program in the schools, through the churches, partner with the local governments?



Work with the TCSO on enforcement.

TVHC services, programs, and resources available to respond to this need include: 

Free concussion baseline screenings



High altitude safety materials



Sun safety materials (and sunscreen giveaways)



Free bystander CPR training



Education on seat belts and safety for adolescent drivers



Newspaper ads for safety regarding helmet use during activities like skiing, snowboarding, and ATV use (“Got Brains”)

Additionally, TVHC plans to take the following steps to address this need: 

As TVHC seeks Level IV Trauma designation, TVHC will implement processes to assess causes for accidents and provide education on prevention



Begin tracking and monitoring the types of accidents presenting at the Hospital to help focus prevention efforts

Anticipated results from TVHC Implementation Strategy Community Benefit Attribute Element

Yes, Implementation Strategy Addresses

1. Available to public and serves low income consumers

X

2. Reduces barriers to access services (or, if ceased, would result in access problems)

X

3. Addresses disparities in health status among different populations

X

4. Enhances public health activities

X

Implementation Strategy Does Not Address

5. Improves ability to withstand public health emergency

X

6. Otherwise would become responsibility of government or another tax-exempt organization

X

7. Increases knowledge; then benefits the public

X

The strategy to evaluate TVHC intended actions is to monitor change in the following Leading Indicator:

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

Number of concussion screenings offered = 111 provided in 2015

The change in the Leading Indicator anticipates appropriate change in the following Lagging Indicator: 

Accidental Deaths 

Teton rate = 68.2 per 100,000 population

TVHC anticipates collaborating with the following other facilities and organizations to address this Significant Need: Organization

Contact Name

Contact Information

Teton County Sheriff’s Office

(208) 354-2323

TC School District 401

(208) 354-2207

TC Fire District

(208) 354-2760

TV Search and Rescue

(208) 354-2591

Other local resources identified during the CHNA process that are believed available to respond to this need: Organization

Contact Name

Contact Information

Idaho Extension 4Hprograms

(208) 354-2961

Yostmark Avalanche Safety Trainings

(208) 354-2828

Grand Targhee Ski Resort (Safety Week)

(307) 353-2300

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Other Needs Identified During CHNA Process 6. PALLIATIVE CARE AND HOSPICE – 2013 Significant Need 7. ALZHEIMER’S 8. ACCESS TO EXERCISE OPPORTUNITIES 9. CANCER 10. FLU/PNEUMONIA 11. OBESITY/OVERWEIGHT 12. HEART DISEASE 13. TEEN BIRTHS 14. CHOLESTEROL (HIGH) 15. PHYSICIAN 16. SEXUAL ASSAULT 17. COMPLIANCE BEHAVIOR – 2013 Significant Need 18. LUNG DISEASE 19. PRIORITY POPULATIONS 20. STROKE 21. DENTAL 22. DIABETES 23. PARKINSON’S

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Overall Community Need Statement and Priority Ranking Score Significant needs where hospital has implementation responsibility28 1. Affordability/Accessibility 2. Mental Health/Suicide 3. Prevention/Wellness 5. Accidents

Significant needs where hospital did not develop implementation strategy29 4. Alcohol Abuse/Substance Abuse

Other needs where hospital developed implementation strategy None

Other needs where hospital did not develop implementation strategy 6. PALLIATIVE CARE AND HOSPICE – 2013 Significant Need 7. ALZHEIMER’S 8. ACCESS TO EXERCISE OPPORTUNITIES 9. CANCER 10. FLU/PNEUMONIA 11. OBESITY/OVERWEIGHT 12. HEART DISEASE 13. TEEN BIRTHS 14. CHOLESTEROL (HIGH) 15. PHYSICIAN 16. SEXUAL ASSAULT 17. COMPLIANCE BEHAVIOR – 2013 Significant Need 18. LUNG DISEASE 19. PRIORITY POPULATIONS

28 29

Responds to Schedule h (Form 990) Part V B 8 Responds to Schedule h (Form 990) Part V Section B 8

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20. STROKE 21. DENTAL 22. DIABETES 23. PARKINSON’S

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APPENDIX

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Appendix A – Written Commentary on Prior CHNA Hospital solicited written comments about its 2013 CHNA.30 26 individuals responded to the request for comments. The following presents the information received in response to the solicitation efforts by the hospital. No unsolicited comments have been received.

1. Please indicate which (if any) of the following characteristics apply to you. If none of the following choices apply to you, skip the indication and please continue to the next question.

Local Experts Offering Solicited Written Comments on 2013 Yes (Applies Priorities and Implementation Strategy to Me) 1) Public Health Expertise 1 2) Departments and Agencies with relevant data/information regarding health needs of the community served by the hospital 2 3) Priority Populations 5 4) Representative/Member of Chronic Disease Group or Organization 1 5) Represents the Broad Interest of the Community 15 Other Answered Question Skipped Question



30

No (Does Not Apply to Me) 22

Response Count 23

20 18

22 23

22 9

23 24 24 2

Within the county, do you perceive the local Priority Populations to have any unique needs, as well as potential unique health issues needing attention? If you believe any situation as described exists, please also indicate who you think needs to do what.

▪

Family planning (birth control) for low income families and teens. Better nutrition and healthy school lunch programs at our public schools.

▪

I would guess we do have priority populations needing help, including Hispanic, low-income, women & children. I don't know who needs to do what.

▪

Most all of the priority populations likely struggle with transportation which I feel is unique to this area.

▪

1. We have a large, underserved Hispanic population in Teton County, that has specific needs in the areas of education, health & human services, poverty-reduction, language services (ESL, translation, etc.) and legal representation. 2. We have a rural population where the needs of the youth, impoverished, elderly, disabled, mentally ill and addicted are grossly underserved. The obstacles to service are many, including: a lack of a formal network of providers; a lack of high-quality resources; lack of funding from the federal, state and local governments; a culture of isolation and the belief in "pulling oneself up by the bootstraps"; perception of a lack of privacy and confidentiality in a rural community; language and cultural barriers within the Hispanic community; and finally, deep divisions within the community at large, running along parallel lines of religion, politics and culture. I deeply believe, however, that even with all of these challenges, our community has plenty of opportunity to engage in deep, powerful change. There are many things we do have, including: a passionate, deeply committed nonprofit community; a culture of generosity; a highly engaged volunteer base; a well-educated,

Responds to IRS Schedule h (Form 990) Part V B 5

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talented and vibrant community; a subset of second homeowners with high levels of wealth and influence. As a rural community with very finite resources, it's everyone's responsibility to help, including the nonprofit sector, state and local government entities, the school district, the hospital, individual volunteers and donors and on and on.

▪

Mental health welness. Everyone especially teenagers

▪

mental health support for community members in crisis

▪

Given the high hispanic demographic in Driggs and Teton County general there are undoubtedly specific needs, but I am not familiar with them. Given the high poverty rate (as measured by free and reduced school lunches) in Driggs specifically I imagine there are unique needs, but again I am not familiar with them.

▪

I believe specific populations have unique needs (access to health care, lack of insurance, language barriers, transportation issues, etc.) and I don't know if I have enough knowledge to answer who needs to do what. Generally, I believe we all need to be observant to our changing populations and needs.

Thus, schools boards & administrators, teachers, local gov't, non-profit employees, EDs and board members and community members need to seek to understand and be ready to take action.

▪

Domestic violence sexual assault victims

▪

Yes, people that are not US citizens.

▪

LGBT--social support lacking

2. In the last process, several data sets were examined and a group of local people were involved in advising the Hospital. While multiple needs emerged, the Hospital had to determine what issues were of high priority and where it would be a valuable resource to assist in obtaining improvements.

Priorities from the last assessment where the Hospital intended to seek improvement were: 

Affordability



Mental Health/Suicide



Alcohol Abuse/Substance Abuse



Accidents



Prevention/Wellness



Compliance Behavior

Comments or observations about this set of needs being the most appropriate for the Hospital to take on in seeking improvements? 

Should the Hospital continue to consider each need identified as most important in the 2013 CHNA report as the most important set of health needs currently confronted residents in the county?

Yes

Affordability Mental Health/Suicide Alcohol Abuse/Substance Abuse Palliative Care and Hospice

No 19 16 19 14

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No Opinion 0 3 1 4

7 7 6 8 Page 48 Proprietary and Confidential

Accidents Prevention/Wellness Compliance Behavior











15 18 13

3 1 5

8 7 8

Specific comments or observations about Affordability as being among the most significant needs for the Hospital to work on to seek improvements?

▪

Health care is expensive in general. Not sure how many people take part in the annual blood draw or utilize discounted services.

▪

I agree that this is a top priority, especially in a rural community that is a 90+ minute drive away from a populated area offering more competitively priced healthcare options. Such travel is not realistic for most of us.

▪

Affordability of insurance is a continuing problem. Even more significant is the coverage available.

The insurance plans provide catastrophic coverage rather than full coverage.

Specific comments or observations about Mental Health/Suicide as being among the most significant needs for the Hospital to work on to seek improvements?

▪

Very involved in the mental health of the community...nothing more required.

▪

Absolutely agree with this. Our suicide rates are shamefully high and the obstacles to adequate, high-quality mental healthcare in our community are huge.

▪

Poor mental health contributes to many of these other issues.

▪

Mental health coverage is limited by insurers, creating an additional barrier.

Specific comments or observations about Alcohol Abuse/Substance Abuse as being among the most significant needs for the Hospital to work on to seek improvements?

▪

Agreed. Currently, there are absolutely zero local options for high-quality substance abuse treatment. Residents must travel to Jackson, WY or to the Rexburg/Idaho Falls area. This is an unrealistic obstacle to service for many.

▪

Substance and alcohol abuse is a significant challenge facing almost every community. Early education is helpful in preventing abuse.

Specific comments or observations about Palliative Care and Hospice as being among the most significant needs for the Hospital to work on to seek improvements?

▪

I am completely ignorant on this issue and cannot offer any helpful insights. However, I do believe this need is currently being met by Avalon.

▪

See previous comments on this topic.

Specific comments or observations about Accidents as being among the most significant needs for the Hospital to work on to seek improvements?

▪

I am unclear on this topic, also. I had no idea our accident rates were so high.

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▪





There are a lot of unsafe behaviors in the community. It is common to see children and adults not using their seatbelts.

Specific comments or observations about Prevention/Wellness as being among the most significant needs for the Hospital to work on to seek improvements?

▪

I need a better description of Prevention/Wellness to offer any helpful insights.

▪

Wellness and prevention efforts are of paramount importance.

Specific comments or observations about Compliance Behavior as being among the most significant needs for the Hospital to work on to seek improvements?

▪

I'd love to hear what medical professionals have to say about this topic, as I am uninformed and am surely guilty of this myself.

3. Comments and observations about the implementation actions of the Hospital to seek health status improvement? 

Should the Hospital continue to allocate resources to assist improving the needs?

Yes

Affordability Mental Health/Suicide Alcohol Abuse/Substance Abuse Palliative Care and Hospice Accidents Prevention/Wellness Compliance Behavior





No 18 18 15 14 12 18 11

No Opinion 1 1 3 3 4 0 4

0 0 1 2 3 1 4

Specific comments and observations about the implementation actions of the Hospital seeking improvement in Affordability?

▪

1. Since our rates of health insurance were so low in 2013, perhaps a program aimed at providing assistance in applying for benefits could be helpful. Not sure how much as changed with the Affordable Health Care Act, though, so this may no longer be a necessity? 2. An increase in funds raised by the hospital to help cover indigent care and/or provide financial assistance to working families would also be useful. Perhaps this would be a good fit for the Hospital Foundation? It's a very compelling cause and could be marketed to the public and potential donors as a way to keep overall costs down for everyone.

▪

This must be legislated.

Specific comments and observations about the implementation actions of the Hospital seeking improvement in Mental Health/Suicide?

▪

Currently very involved and supportive of the mental health community and their projects.

▪

Collaboration with the newly formed Community Resource Center. Collaboration with SPAN and Teton

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Valley Mental Health Coalition to further resources for free and subsidized counseling. These two organizations new, small, all-volunteer organizations that are limited by their capacity and could use assistance in procuring resources.

▪ 











Support crisis counseling. Continue telepsychiatry.

Specific comments and observations about the implementation actions of the Hospital seeking improvement in Alcohol Abuse/Substance Abuse?

▪

I dream of the day when we can support a nonprofit substance abuse treatment center in Teton Valley.

Any efforts by TVHC to bring this much needed resource into fruition would be incredibly appreciated.

There are many, many challenges to working on a project of this scope, but the rewards would multiply exponentially and would include reductions in violence, poverty, accidents, crime, suicide, etc.

▪

Consider supporting AA and NA chapters.

Specific comments and observations about the implementation actions of the Hospital seeking improvement in Palliative Care and Hospice?

▪

n/a

▪

Public education on topic as well as internal education for physicians.

Specific comments and observations about the implementation actions of the Hospital seeking improvement in Accidents?

▪

Community education program in the schools, through the churches, partner with the local governments?

▪

Work with the TCSO on enforcement.

Specific comments and observations about the implementation actions of the Hospital seeking improvement in Prevention/Wellness?

▪

Community education program in the schools, through the churches, partner with the local governments?

▪

A patient's physician must champion the need for prevention and wellness.

Specific comments and observations about the implementation actions of the Hospital seeking improvement in Compliance Behavior?

▪

Community education program in the schools, through the churches, partner with the local governments?

▪

I'm not sure how to address this concern. Perhaps it would be helpful for patient advice to be given in a way that would be more easily adopted by the patient. For example, instead of 'stop smoking', offer available resources and suggest one less cigarette daily. Future visits could build on the one less per day suggestion.

Do you have opinions about new or additional implementation efforts or community needs the Hospital should pursue?

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

▪

Teenage pregnancy, and drug/alcohol use.

▪

Food/nutrition and family planning

▪

I would love to see an increase in collaborative efforts with the health and human service nonprofits in Teton Valley. In addition to the incredible work TVHC is already doing with the newly formed Community Resource Center and the Teton Valley Food Pantry, I'd like to see the hospital collaborate with some of the other local nonprofits (if capacity allows), such as: Seniors West of the Tetons, Teton Valley Education Foundation, Connections Family Resource Center, Driggs Head Start, Family Safety Network, Subs for Santa, SPAN, Teton Valley Mental Health Coalition, Hispanic Resource Center and Valley of the Tetons Libraries. (Apologies if this is already happening and I just don't know about it!)

There are also opportunities to partner with local service organizations such as Rotary, Church in the Tetons, St. Francis Episcopal Church, the LDS Church/ Relief Society, etc.

▪

Improvement of billing processes. Delay in billing and insurance submittals means that people routinely receive bills for healthcare which occurred 6-12 months in the past. This makes it hard to identify errors in billing or insurance reimbursement.

▪

Expand availability of specialists.

Finally, after thinking about our questions and the information we seek, is there anything else you think important as we review and revise our thinking about significant health needs within the county?

▪

I am a huge believer in the power of collaboration within this incredible community of ours and am absolutely convinced that together, we have what it takes to engage in positive social change in Teton Valley. Many, many thanks to TVHC for their efforts along these lines.

▪

Continue to develop ties with the community

▪

Please have health care providers trained to assess suicidal individuals in the ER.

▪

Many people in the valley seek care from non-licensed, inadequately trained practitioners. Most of the time it works out fine, but sometimes it does not. The hospital should reach out to residents and provide the care they seek.

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Appendix B – Identification & Prioritization of Community Needs

Individuals Participating as Local Expert Advisors31 Local Experts Offering Solicited Written Comments on 2013 Yes (Applies Priorities and Implementation Strategy to Me) 1) Public Health Expertise 5 2) Departments and Agencies with relevant data/information regarding health needs of the community served by the hospital 3 3) Priority Populations 3 4) Representative/Member of Chronic Disease Group or Organization 1 5) Represents the Broad Interest of the Community 16 Other Answered Question Skipped Question

31

No (Does Not Apply to Me) 4

Response Count 19

15 14

18 17

16 3

17 19 21 0

Responds to IRS Schedule h (Form 990) Part V B 3 g

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Advice Received from Local Expert Advisors Question: Do you agree with the observations formed about the comparison of Teton County to all other Idaho counties?

Comments: 

I disagree with the access to exercise opportunities being low, when I think about the outdoor activities that are prevalent in our county, I consider these exercise opportunities. I think of areas like Burley and Buhl and Minidoka and feel like we've got a lot more going on. I know these are all outside, but still feel that we have a lot of exercise opportunities, perhaps not everyone is taking advantage of these opportunities.



Services for people suffering from mental health issues are more available, accessible and appropriate than in other rural communities.



I disagree with the access to exercise opportunities. How much better can access to exercise get than the wide open spaces (always free), sports offered by the community rec. program (very inexpensive), and private establishments, like dance studio's, rock climbing gym, gymnastics, and Grand Targhee?



Access to exercise opportunities is both free and plentiful.

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Question: Do you agree with the observations formed about the comparison of Teton County to its peer counties?

Comments: 

Limited access to parks is interesting. We have locations that may not be considered parks, but I feel are exercise opportunities (pathways, groomed nordic trails, mountains, streams, etc...)



Don't agree that 0.0% of individuals don't live within a half mile of a park.



I disagree with the Physical Environment stat - Access to Parks: I believe the access to parks in our cities is on par if not far above the peer average, though the facilities themselves may not be as comprehensively developed. It is entirely possible that people live adjacent to a park without realizing it. If someone lives in any of the three cities in Teton County they most likely live within a half mile of a park or school grounds. Teton County School District has made their facilities available to the public, thus should also be counted as parks. Furthermore, I believe that the very character of our landscape qualifies in many ways as a 'park' i.e. open, undeveloped space, and therefore should be counted as 'park' within the unincorporated county.



The access to Parks figure is clearly inaccurate. There are numerous parks in the Cities of Driggs and Victor, with decent populations living within a half mile.



Parks? We are not a huge city. We have thousands of acres right out the back door.

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Question: Do you agree with the observations formed about the population characteristics of Teton County?

Comments: 

I don't know what "Used Midlevel in last 6 months" means.

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Question: Do you agree with the observations formed from the national ranking and leading causes of death?

Comments: 

Any study based on Teton County population is flawed because of our high transient nature. Not all transients in our county fit the traditional definition of disadvantaged or low income. Many of our 'transients' are second home owners, who may live here for a large portion of the year, but don't call this place home. I don't know if there is any way to incorporate this information into the study, but believe it might warrant a note or addendum calling attention to it.

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Question: Do you agree with the written comments received on the 2013 CHNA??

Comments: 

Agree with all except the one to "increase collaborative effort." Would add: Cost of Healthcare insurance. Would like to hear what the healthcare industry suggests to make insurance more affordable/reasonable and available to all income levels within our community. And, what is TVHC doing to get medicaid or insurance for the individuals that are in the "gap" - those who make to much to get medicaid but not enough to get insurance on the Idaho exchange.



I am personally aware of, and have heard frequent comments from others about significant problems with billing processes (accuracy and timeliness). This is a primary reason I actively avoid the TVHC facilities when possible. I've also personally observed excessive costs on specialty testing here vs. in larger population centers like Jackson or Idaho Falls.



Bilingual mental health professionals are practically non existent in the valley. The Hispanic minority does not seem to be represented in that area

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Question: Do you agree with the additional written comments received on the 2013 CHNA?

Comments: 

I'd emphasize 'accidents' as a higher priority. I like the high 'prevention/wellness' emphasis. I'm not sure what 'compliance behavior' means.



Affordability--the hospital has a charity policy to reduce expenses and staff to assist in applying for health insurance. Mental health and substance abuse --I agree are issues facing our community. Rather than assuming responsibility for treatment I would like financial support provided to existing organizations.

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Appendix C – National Healthcare Quality and Disparities Report The National Healthcare Quality and Disparities Reports (QDR) are annual reports to Congress mandated in the Healthcare Research and Quality Act of 1999 (P.L. 106-129). These reports provide a comprehensive overview of the quality of healthcare received by the general U.S. population and disparities in care experienced by different racial, ethnic, and socioeconomic groups. The purpose of the reports is to assess the performance of our health system and to identify areas of strengths and weaknesses in the healthcare system along three main axes: access to healthcare, quality of healthcare, and priorities of the National Quality Strategy (NQS).

The reports are based on more than 250 measures of quality and disparities covering a broad array of healthcare services and settings. Data are generally available through 2012, although rates of un-insurance have been tracked through the first half of 2014. The reports are produced with the help of an Interagency Work Group led by the Agency for Healthcare Research and Quality (AHRQ) and submitted on behalf of the Secretary of Health and Human Services (HHS).

Beginning with this 2014 report, findings on healthcare quality and healthcare disparities are integrated into a single document. This new National Healthcare Quality and Disparities Report (QDR) highlights the importance of examining quality and disparities together to gain a complete picture of healthcare. This document is also shorter and focuses on summarizing information over the many measures that are tracked; information on individual measures will still be available through chartbooks posted on the Web (www.ahrq.gov/research/findings/nhqrdr/2014chartbooks/).

The key findings of the 2014 QDR are organized around three axes: access to healthcare, quality of healthcare, and NQS priorities.

To obtain high-quality care, Americans must first gain entry into the healthcare system. Measures of access to care tracked in the QDR include having health insurance, having a usual source of care, encountering difficulties when seeking care, and receiving care as soon as wanted. Historically, Americans have experienced variable access to care based on race, ethnicity, socioeconomic status, age, sex, disability status, sexual orientation, and residence location.

ACCESS: After years without improvement, the rate of un-insurance among adults ages 18-64 decreased substantially during the first half of 2014.

The Affordable Care Act is the most far-reaching effort to improve access to care since the enactment of Medicare and Medicaid in 1965. Provisions to increase health insurance options for young adults, early retirees, and Americans with pre-existing conditions were implemented in 2010. Open enrollment in health insurance marketplaces began in October 2013 and coverage began in January 2014. Expanded access to Medicaid in many states began in January 2014, although a few had opted to expand Medicaid earlier.

Trends 

From 2000 to 2010, the percentage of adults ages 18-64 who reported they were without health insurance coverage at the time of interview increased from 18.7% to 22.3%.



From 2010 to 2013, the percentage without health insurance decreased from 22.3% to 20.4%.



During the first half of 2014, the percentage without health insurance decreased to 15.6%.

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

Data from the Gallup-Healthways Well-Being Index indicate that the percentage of adults without health insurance continued to decrease through the end of 2014,32 consistent with these trends.

ACCESS: Between 2002 and 2012, access to health care improved for children but was unchanged or significantly worse for adults.

Trends 

From 2002 to 2012, the percentage of people who were able to get care and appointments as soon as wanted improved for children but did not improve for adults ages 18-64.

Disparities 

Children with only Medicaid or CHIP coverage were less likely to get care as soon as wanted compared with children with any private insurance in almost all years.



Adults ages 18-64 who were uninsured or had only Medicaid coverage were less likely to get care as soon as wanted compared with adults with any private insurance in all years.

Trends 

Through 2012, most access measures improved for children. The median change was 5% per year.



Few access measures improved substantially among adults. The median change was zero.

ACCESS DISPARITIES: During the first half of 2014, declines in rates of un-insurance were larger among Black and Hispanic adults ages 18-64 than among Whites, but racial differences in rates remained.

Trends 

Historically, Blacks and Hispanics have had higher rates of un-insurance than Whites.33

Disparities 

During the first half of 2014, the percentage of adults ages 18-64 without health insurance decreased more quickly among Blacks and Hispanics than Whites, but differences in un-insurance rates between groups remained.



Data from the Urban Institute’s Health Reform Monitoring System indicate that between September 2013 and September 2014, the percentage of Hispanic and non-White non-Hispanic adults ages 18-64 without health insurance decreased to a larger degree in states that expanded Medicaid under the Affordable Care Act than in states that did not expand Medicaid.34

ACCESS DISPARITIES: In 2012, disparities were observed across a broad spectrum of access measures. People in poor households experienced the largest number of disparities, followed by Hispanics and Blacks.

Disparities

32

Levy J. In U.S., Uninsured Rate Sinks to 12.9%. http://www.gallup.com/poll/180425/uninsured-rate-sinks. aspx.

In this report, racial groups such as Blacks and Whites are non-Hispanic, and Hispanics include all races.

34 Long SK, Karpman M, Shartzer A, et al. Taking Stock: Health Insurance Coverage under the ACA as of September 2014. http://hrms.urban.org/briefs/Health-Insurance-Coverage-under-the-ACA-as-of- September-2014.html 33

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

In 2012, people in poor households had worse access to care than people in high-income households on all access measures (green).



Blacks had worse access to care than Whites for about half of access measures.



Hispanics had worse access to care than Whites for two-thirds of access measures.



Asians and American Indians and Alaska Natives had worse access to care than Whites for about one-third of access measures.

ACCESS DISPARITIES: Through 2012, across a broad spectrum of access measures, some disparities were reduced but most did not improve.

Disparity Trends 

Through 2012, most disparities in access to care related to race, ethnicity, or income showed no significant change (blue), neither getting smaller nor larger.



In four of the five comparisons shown above, the number of disparities that were improving (black) exceeded the number of disparities that were getting worse (green).

QUALITY: Quality of health care improved generally through 2012, but the pace of improvement varied by measure.

Trends 

Through 2012, across a broad spectrum of measures of health care quality, 60% showed improvement (black).



Almost all measures of Person-Centered Care improved.



About half of measures of Effective Treatment, Healthy Living, and Patient Safety improved.



There are insufficient numbers of reliable measures of Care Coordination and Care Affordability to summarize in this way.

QUALITY: Through 2012, the pace of improvement varied across NQS priorities.

Trends 

Through 2012, quality of health care improved steadily but the median pace of change varied across NQS priorities: ▪

Median change in quality was 3.6% per year among measures of Patient Safety.

▪

Median improvement in quality was 2.9% per year among measures of Person-Centered Care.

▪

Median improvement in quality was 1.7% per year among measures of Effective Treatment.

▪

Median improvement in quality was 1.1% per year among measures of Healthy Living.

▪

There were insufficient data to assess Care Coordination and Care Affordability.

QUALITY: Publicly reported CMS measures were much more likely than measures reported by other sources to achieve high levels of performance.

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Achieved Success Eleven quality measures achieved an overall performance level of 95% or better this year. At this level, additional improvement is limited, so these measures are no longer reported in the QDR. Of measures that achieved an overall performance level of 95% or better this year, seven were publicly reported by CMS on the Hospital Compare website (italic). 

Hospital patients with heart attack given percutaneous coronary intervention within 90 minutes



Adults with HIV and CD4 cell count of 350 or less who received highly active antiretroviral therapy during the year



Hospital patients with pneumonia who had blood cultures before antibiotics were administered



Hospital patients age 65+ with pneumonia who received pneumococcal screening or vaccination



Hospital patients age 50+ with pneumonia who received influenza screening or vaccination



Hospital patients with heart failure and left ventricular systolic dysfunction who were prescribed angiotensinconverting enzyme or angiotensin receptor blocker at discharge



Hospital patients with pneumonia who received the initial antibiotic dose consistent with current recommendations



Hospital patients with pneumonia who received the initial antibiotic dose within 6 hours of arrival



Adults with HIV and CD4 cell counts of 200 or less who received Pneumocystis pneumonia prophylaxis during the year



People with a usual source of care for whom health care providers explained and provided all treatment options



Hospice patients who received the right amount of medicine for pain management

Last year, 14 of 16 quality measures that achieved an overall performance level of 95% or better were publicly reported by CMS. Measures that reach 95% and are no longer reported in the QDR continue to be monitored when data are available to ensure that they do not fall below 95%.

Improving Quickly Through 2012, a number of measures showed rapid improvement, defined as an average annual rate of change greater than 10% per year. Of these measures that improved quickly, four are adolescent vaccination measures (italic). 

Adolescents ages 16-17 years who received 1 or more doses of tetanus-diphtheria-acellular pertussis vaccine



Adolescents ages 13-15 years who received 1 or more doses of tetanus-diphtheria-acellular pertussis vaccine



Hospital patients with heart failure who were given complete written discharge instructions



Adolescents ages 16-17 years who received 1 or more doses of meningococcal conjugate vaccine



Adolescents ages 13-15 years who received 1 or more doses of meningococcal conjugate vaccine



Patients with colon cancer who received surgical resection that included 12+ lymph nodes pathologically

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examined 

Central line-associated bloodstream infection per 1,000 medical and surgical discharges, age 18+ or obstetric admissions



Women with Stage I-IIb breast cancer who received axillary node dissection or sentinel lymph node biopsy at time of surgery

Worsening Through 2012, a number of measures showed worsening quality. Of these measures that showed declines in quality, three track chronic diseases (italic). Note that these declines occurred prior to implementation of most of the health insurance expansions included in the Affordable Care Act. 

Maternal deaths per 100,000 live births



Children ages 19-35 months who received 3 or more doses of Haemophilus influenzae type b vaccine



People who indicate a financial or insurance reason for not having a usual source of care



Suicide deaths per 100,000 population



Women ages 21-65 who received a Pap smear in the last 3 years



Admissions with diabetes with short-term complications per 100,000 population, age 18+



Adults age 40+ with diagnosed diabetes who had their feet checked for sores or irritation in the calendar year



Women ages 50-74 who received a mammogram in the last 2 years



Postoperative physiologic and metabolic derangements per 1,000 elective-surgery admissions, age 18+



People with current asthma who are now taking preventive medicine daily or almost daily



People unable to get or delayed in getting needed medical care, dental care, or prescription medicines due to financial or insurance reasons

QUALITY DISPARITIES: Disparities remained prevalent across a broad spectrum of quality measures. People in poor households experienced the largest number of disparities, followed by Blacks and Hispanics.

Disparities 

People in poor households received worse care than people in high-income households on more than half of quality measures (green).



Blacks received worse care than Whites for about one-third of quality measures.



Hispanics, American Indians and Alaska Natives, and Asians received worse care than Whites for some quality measures and better care for some measures.



For each group, disparities in quality of care are similar to disparities in access to care, although access problems are more common than quality problems.

QUALITY DISPARITIES: Through 2012, some disparities were getting smaller but most were not improving across a broad spectrum of quality measures.

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Disparity Trends 

Through 2012, most disparities in quality of care related to race, ethnicity, or income showed no significant change (blue), neither getting smaller nor larger.



When changes in disparities occurred, measures of disparities were more likely to show improvement (black) than decline (green). However, for people in poor households, more measures showed worsening disparities than improvement.

QUALITY DISPARITIES: Through 2012, few disparities in quality of care were eliminated while a small number became larger.

Disparities Trends 

Through 2012, several disparities were eliminated.

▪

One disparity in vaccination rates was eliminated for Blacks (measles-mumps-rubella), Asians (influenza), American Indians and Alaska Natives (hepatitis B), and people in poor households (human papillomavirus).

▪

Four disparities related to hospital adverse events were eliminated for Blacks.

▪

Three disparities related to chronic diseases and two disparities related to communication with providers were eliminated for Asians.

▪

On the other hand, a few disparities grew larger because improvements in quality for Whites did not extend uniformly to other groups.

▪

At least one disparity related to hospice care grew larger for Blacks, American Indians and Alaska Natives, and Hispanics.

▪

People in poor households experienced worsening disparities related to chronic diseases.

QUALITY DISPARITIES: Overall quality and racial/ethnic disparities varied widely across states and often not in the same direction.

Geographic Disparities 

There was significant variation in quality among states. There was also significant variation in disparities.



States in the New England, Middle Atlantic, West North Central, and Mountain census divisions tended to have higher overall quality while states in the South census region tended to have lower quality.



States in the South Atlantic, West South Central, and Mountain census divisions tended to have fewer racial/ethnic disparities while states in the Middle Atlantic, West North Central, and Pacific census divisions tended to have more disparities.



The variation in state performance on quality and disparities may point to differential strategies for improvement.

National Quality Strategy: Measures of Patient Safety improved, led by a 17% reduction in hospital-acquired conditions.

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Hospital-acquired conditions have been targeted for improvement by the CMS Partnership for Patients initiative, a major public-private partnership working to improve the quality, safety, and affordability of health care for all Americans. As a result of this and other federal efforts, such as Medicare’s Quality Improvement Organizations and the HHS National Action Plan to Prevent Health Care-Associated Infections, as well as the dedication of practitioners, the general trend in patient safety is one of improvement.

Trends 

From 2010 to 2013, the overall rate of hospital-acquired conditions declined from 145 to 121 per 1,000 hospital discharges.



This decline is estimated to correspond to 1.3 million fewer hospital-acquired conditions, 50,000 fewer inpatient deaths, and $12 billion savings in health care costs.35



Large declines were observed in rates of adverse drug events, healthcare-associated infections, and pressure ulcers.



About half of all Patient Safety measures tracked in the QDR improved.



One measure, admissions with central line-associated bloodstream infections, improved quickly, at an average annual rate of change above 10% per year.



One measure, postoperative physiologic and metabolic derangements during elective-surgery admissions, got worse over time.

Disparities Trends 

Black-White differences in four Patient Safety measures were eliminated.



Asian-White differences in admissions with iatrogenic pneumothorax grew larger.

National Quality Strategy: Measures of Person-Centered Care improved steadily, especially for children.

Trends 

From 2002 to 2012, the percentage of children whose parents reported poor communication significantly decreased overall and among all racial/ethnic and income groups.



Almost all Person-Centered Care measures tracked in the QDR improved; no measure got worse.

Disparities In almost all years, the percentage of children whose parents reported poor communication with their health providers was: 

Higher for Hispanics and Blacks compared with Whites.



Higher for poor, low-income, and middle-income families compared with high-income families.

Disparities Trends 35

Agency for Healthcare Research and Quality. Interim Update on 2013 Annual Hospital-Acquired Condition Rate and Estimates of Cost Savings and Deaths Averted From 2010 to 2013. http://www.ahrq.gov/professionals/quality-patient-safety/pfp/interimhacrate2013.html

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

Asian-White differences in two measures related to communication were eliminated.



Four Person-Centered Care disparities related to hospice care grew larger.

National Quality Strategy: Measures of Care Coordination improved as providers enhanced discharge processes and adopted health information technologies.

Trends 

From 2005 to 2012, the percentage of hospital patients with heart failure who were given complete written discharge instructions increased overall, for both sexes, and for all racial/ethnic groups.



There are few measures to assess trends in Care Coordination.

Disparities 

In all years, the percentage of hospital patients with heart failure who were given complete written discharge instructions was lower among American Indians and Alaska Natives compared with Whites.

National Quality Strategy: Many measures of Effective Treatment achieved high levels of performance, led by measures publicly reported by CMS on Hospital Compare.

Trends 

From 2005 to 2012, the percentage of hospital patients with heart attack given percutaneous coronary intervention within 90 minutes of arrival increased overall, for both sexes, and for all racial/ethnic groups.



In 2012, the overall rate exceeded 95%; the measure will no longer be reported in the QDR.



Eight other Effective Treatment measures achieved overall performance levels of 95% or better this year, including five measures of pneumonia care and two measures of HIV care.



About half of all Effective Treatment measures tracked in the QDR improved.



Two measures, both related to cancer treatment, improved quickly, at an average annual rate of change above 10% per year.



Three measures related to management of chronic diseases got worse over time.

Disparities 

As rates topped out, absolute differences between groups became smaller. Hence, disparities often disappeared as measures achieved high levels of performance.

Disparities Trends 

Asian-White differences in three chronic disease management measures were eliminated but income-related disparities in two measures related to diabetes and joint symptoms grew larger.

National Quality Strategy: Healthy Living improved in about half of the measures followed, led by selected adolescent vaccines from 2008 to 2012.

Trends

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

From 2008 to 2012, the percentage of adolescents ages 16-17 years who received 1 or more doses of meningococcal conjugate vaccine increased overall, for residents of both metropolitan and nonmetropolitan areas, and for all income groups.



About half of all Healthy Living measures tracked in the QDR improved.



Four measures, all related to adolescent immunizations, improved quickly, at an average annual rate of change above 10% per year (meningococcal vaccine ages 13-15 and ages 16-17; tetanusdiphteria-acellular pertussis vaccine ages 13-15 and ages 16-17).



Two measures related to cancer screening got worse over time.

Disparities 

Adolescents ages 16-17 in nonmetropolitan areas were less likely to receive meningococcal conjugate vaccine than adolescents in metropolitan areas in all years.



Adolescents in poor, low-income, and middle-income households were less likely to receive meningococcal conjugate vaccine than adolescents in high-income households in almost all years.

Disparities Trends 

Four disparities related to child and adult immunizations were eliminated.



Black-White differences in two Healthy Living measures grew larger.

National Quality Strategy: Measures of Care Affordability worsened from 2002 to 2010 and then leveled off.

From 2002 to 2010, prior to the Affordable Care Act, care affordability was worsening. Since 2010, the Affordable Care Act has made health insurance accessible to many Americans with limited financial resources.

Trends 

From 2002 to 2010, the overall percentage of people unable to get or delayed in getting needed medical care, dental care, or prescription medicines and who indicated a financial or insurance reason rose from 61.2% to 71.4%.



From 2002 to 2010, the rate worsened among people with any private insurance and among people from highand middle-income families; changes were not statistically significant among other groups.



After 2010, the rate leveled off, overall and for most insurance and income groups.



Data from the Commonwealth Fund Biennial Health Insurance Survey indicate that cost-related problems getting needed care fell from 2012 to 2014 among adults.36



Another Care Affordability measure, people without a usual source of care who indicate a financial or insurance reason for not having a source of care, also worsened from 2002 to 2010 and then leveled off.

36

Collins SR, Rasmussen PW, Doty MM, et al. The Rise in Health Care Coverage and Affordability Since Health Reform Took Effect: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2014. http://www.commonwealthfund.org/~/media/files/publications/issuebrief/2015/jan/1800_collins_biennial_survey_brief.pdf?la=en

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

There are few measures to assess trends in Care Affordability.

Disparities 

In all years, the percentage of people unable to get or delayed in getting needed medical care, dental care, or prescription medicines who indicated a financial or insurance reason for the problem was: ▪

Higher among uninsured people and people with public insurance compared with people with any private insurance.

▪

Higher among poor, low-income, and middle-income families compared with high-income families.

CONCLUSION The 2014 Quality and Disparities Reports demonstrate that access to care improved. After years of stagnation, rates of un-insurance among adults decreased in the first half of 2014 as a result of Affordable Care Act insurance expansion.

However, disparities in access to care, while diminishing, remained.

Quality of healthcare continued to improve, although wide variation across populations and parts of the country remained. Among the NQS priorities, measures of Person-Centered Care improved broadly. Most measures of Patient Safety, Effective Treatment, and Healthy Living also improved, but some measures of chronic disease management and cancer screening lagged behind and may benefit from additional attention. Data to assess Care Coordination and Affordable Care were limited and measurement of these priorities should be expanded.

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Appendix D – Illustrative Schedule h (Form 990) Part V B Potential Response Illustrative IRS Schedule h Part V Section B (Form 990)37 Community Health Need Assessment Illustrative Answers 1.

Was the hospital facility first licensed, registered, or similarly recognized by a State as a hospital facility in the current tax year or the immediately preceding tax year?

No

2.

Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C No

3.

During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If “No,” skip to line 12. If “Yes,” indicate what the CHNA report describes (check all that apply) a. A definition of the community served by the hospital facility See footnotes 17 and 19 on page 12 b. Demographics of the community See footnote 20 on page 13 c. Existing health care facilities and resources within the community that are available to respond to the health needs of the community See footnote 26 on page 33 and 27 on page 35 d. How data was obtained See footnote 11 on page 8 e. The significant health needs of the community See footnote 25 on page 32 f.

Primary and chronic disease needs and other health issues of uninsured persons, low-income persons, and minority groups See footnote 12 on page 9

g. The process for identifying and prioritizing community health needs and services to meet the community health needs See footnote 31 on page 53 h. The process for consulting with persons representing the community's interests See footnote 8 on page 7 and footnote 9 on page 7

37

Questions are drawn from 2014 Federal 990 schedule h.pdf and may change when the hospital is to make its 990 h filing

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i.

Information gaps that limit the hospital facility's ability to assess the community's health needs See footnote 10 on page 8; footnote 13 on page 9; footnote 14 on page 10; and footnote 23 on page 17

j.

Other (describe in Section C) N/A

4.

Indicate the tax year the hospital facility last conducted a CHNA: 2013

5.

In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If “Yes,” describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted See footnote 15 on page 10 and footnote 30 on page 47

6.

a. Was the hospital facility's CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C See footnote 4 on page 4 and footnote 7 on page 7 b. Was the hospital facility's CHNA conducted with one or more organizations other than hospital facilities? If “Yes,” list the other organizations in Section C No

7.

Did the hospital facility make its CHNA report widely available to the public?

Yes If “Yes,” indicate how the CHNA report was made widely available (check all that apply): a. Hospital facility's website (list URL) www.tvhcare.org b. Other website (list URL) No other website c. Made a paper copy available for public inspection without charge at the hospital facility Yes d. Other (describe in Section C) No other efforts

8.

Did the hospital facility adopt an implementation strategy to meet the significant community health needs identified through its most recently conducted CHNA? If “No,” skip to line 11 See footnotes 28 and 29 on page 44

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9.

Indicate the tax year the hospital facility last adopted an implementation strategy: 20__ 2013

10.

Is the hospital facility's most recently adopted implementation strategy posted on a website? a. If “Yes,” (list url): Yes; www.tvhcare.org b. If “No,” is the hospital facility's most recently adopted implementation strategy attached to this return?

11.

Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed See footnote 27 on page 35

12.

a. Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r) (3)?

None incurred b. If “Yes” to line 12a, did the organization file Form 4720 to report the section 4959 excise tax?

Nothing to report c. If “Yes” to line 12b, what is the total amount of section 4959 excise tax the organization reported on Form4720 for all of its hospital facilities?

Nothing to report

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